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07-30-'11 16:20 FROM-Buckinham Property +559-452-8249 T-731 P0001/0001 F-463 [APPROVEDCalifornia Department of Public Health Compliance FormAnti-Entrapment Devices and Systems Dfor Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE: Use one form for eabh Pump or multiple PUMIDS under the same drain cover, ALL SECTIONS OF THIS FORM MUST BE COMPLETED. This form is to be used to verify compliance with modifications pursuant to the new Health and Safety Code sections 116064.1.and 116064,2. Under Section 116064.2 (a) of the Health and Safety Code, effective January 1, 2010, the owner of a public swimming pool shall file this form within 30 days following the completion of construction or installation of anti-entrapment devices or systems in swimming pools. Contact your local Environmental Health Department and Building Department for any necessary plan approval and permits prior to construction or remodel. Site Information Facility tame: fL Pool Identification (if more than 1 pool/spa at site); -Fa I i Addresa: � r h� . City: S�ir�tr st: Zip:_ Owner Name:Jl Owners Phone Number: X Owners Address')( City,k St„5f ZIPX Pool constructed on or aftef January 1,20107: ❑ Yes No Puqg information �O,teT Pi�oG Recirculation Pump Cl Jet/Booster Pump Make/Model gf/ E,rjp�y�r H.p 1, a Make/Model ❑ Other Pump•_ H.P Make/ModelO Feature Pump KIPMake/Model H P Main Drain includes All Suction Outlets Exce t Skimmer E ualizer Lines Manufacturer of approved drain cover: Model Number: SIX Install date GPM rating:Floor Wall Installed on Floor ❑ Wall �J Manufacturer of approved drain cover; Model Number. Install date Check One: GPM rating:Floor Wall Installed on O Floor ❑Wall Main drain/Jet suction pipe size is inches. O Split main drain(s)(Minimum 3 ft.between covers, hydraulically balanced and symmetrically plumbed) ❑ Single drain-Unblockable(size and shape that a human body cannot sufficiently block to create a Suction entrapment) (Single drain-Not unblockable (one of the following secondary devices required; safety vacuum release system,Suction limiting vent system, gravity drainage system,auto pum shut-off system,or other equally or more effective system approved by enforcement agency) Type of secondary device installed; S`'7: Install date ,5I Manufacturer of approved device: r Model/Part Number: _ Safety vacuum release system bears the followin performance standard markings:13ATSM F2387 ❑ ASME/ANSI standard A 112.19.17 Skimmer Equalizer Line($) Manufacturer of approved suction fitting:-d�� J Model Number. -� Install date GPM rating:GPM rating) Floor Waller Installed on o-Fleor—ti Wall Skimmer equalizer line($)pipe size were found to be inches Number of Skimmers; THE ABOVE HAS BEEN FIELD VERIFiEb TO COMPLY WITH MANUFACTURER'S INSTALLATION RE UIREMENTS BY THE INSTALLER I declare that I hcId an active.California State Contractor license# with classification G Professional Engineer license# - 6//l.ns California State With qualified experience working on public swimming pools andd that hat the information provided above is true to the best of my knowledge. I understand that if i improperly certify this information, I Shall be sub)ect to potential disciplinary action at the discretion of the licensing authority in accordance with California Health&Safety Code Section 116064,2. Contractor/Engineer Name: Company Name: Company Address: City; �^r� +gw - State: Zip Code; ContractorlEngineerPhone Number. .f54-2 1a IJ'q {' •, Cell Phone Number:12-a2 a2 al Contractor/Engineer FAX Number._(j ) .9 :�� Eail / Contractorrname-(�RfNT � ) C9Dc or T /EnginE ame(S ,NATURE) Date -Ora complete text of the law,visit: http://info.son.ca.gov/pub/03-10/bllt/asm/ab_1001-1050/ab_1020 bill 20091011 chapterad.pdf 'V